The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|OCEANS BEHAVIORAL HOSPITAL OF ABILENE||6401 DIRECTORS PARKWAY ABILENE, TX 79606||March 2, 2021|
|VIOLATION: Director of Nursing - Responsibilities||Tag No: A1702|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on a review of documentation and the clinical record, the nursing director failed to direct and monitor the nursing care furnished, as facility policy regarding medication reconcilation was not followed.
Patient #1 was admitted to the facility on on [DATE]. An order for Invega Sustenna was written on 1-25-21, to be started the same day. The order stated that the patient was to receive Invega Sustenna 234 mg intramuscularly on 1-25-21, 156 mg intramuscularly on 1-30-21, 234 mg on 2-28-21 and 234 mg every 28 days after the dose on 2-28-21.
A review of the medication administration record and nursing documentation revealed that patient #1 refused to consent to the Invega Sustenna and never received the initial dose. The patient was discharged on [DATE]. The discharge medication reconciliation form stated that the patient was to receive Invega Sustenna 156 mg on 1-30-21 and Invega Sustenna 234 mg on 2-28-21 (although she had never received the initial dose, to be administered on 1-25-21).
Facility policy MM-14 titled "Reconciled Medications" stated, in part:
Medication reconcilation is the process of comparing a patient's medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors or derug interactions. It should be done at every transition of care in which new medications are ordered or existing orders rewritten...
1. The complete list of the patient's medications will be communicated to the next provider of service when the patient is referred or transferred to another setting.
3. The nurse will review discharge medication reconciliation list with the physician/NPP against the MAR [medication administration record] and other physician order sheets."
The above was confirmed in a telephone interview with the CEO on 3-2-21.